Cohort Intake Form

U.S. Department of Health and Human Services (HHS)
Centers for Disease Control and Prevention (CDC)

SMART2
Page 1 of 13
OMB Control # 0920-XXXX
Expiration Date XX/XX/
XXXX

Cohort Intake
SMART2 ID

__________________________________

We will be contacting someone in your household weekly for 12 weeks for a brief survey whom
we will call "head of household". Who would you like to designate as "head of household"?
Head First Name

__________________________________

Head Last Name

__________________________________

Head Email

__________________________________

What is the best phone number to reach the Head of
Household?

__________________________________

What type of phone is this?

What is a back-up phone number where we could reach
the Head of Household?

Cell
Home
Work
__________________________________
(back-up)

What type of phone is this?

Cell
Home
Work

Would you prefer that we do the weekly surveys over
the phone or that we email a link to a web survey?

Email
Phone

What is your street address?

__________________________________

What city do you live in?

__________________________________

What is your zip code?

__________________________________

What is the Head of Household's gender?

Male
Female

What is the Head of Household's birth month & year?

__________________________________

Has the Head of Household had the flu vaccine for
this season (since August)?

Yes
No
Don't know
(Either flu shot or flu mist)

We would like to ask you some questions about each of the people who normally sleep at your
household or those who you consider part of your household.
HH Member 1

__________________________________
(First name only)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions and
completing and reviewing the collection of information. An agency may not conduct or sponsor this survey, and a person is not required to respond to a
collection of information, unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA 0920-XXXX.

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 2 of 13

What is the relationship of HH1 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation
(relationship to head of household)

HH 1 Gender

Male
Female

Has HH1 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH1 under 19 years old?

Yes
No

HH1 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH1 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school
(Only ask if HH1 is under 19 yrs)

What school does HH1 attend?

What is the name of their school?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other
__________________________________
(Only ask if "other school")

How does HH1 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH1 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH1 first start attending daycare or
preschool regularly?

__________________________________

HH Member 2

__________________________________
(First name only)

What is the relationship of HH2 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation
(relationship to head of household)

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 3 of 13

HH 2 Gender

Male
Female

Has HH2 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH2 under 19 years old?

Yes
No
Don't know

HH 2 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH2 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH2 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

How does HH2 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH2 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH2 first start attending daycare or
preschool regularly?

__________________________________

HH Member 3

__________________________________
(First name only)

What is the relationship of HH3 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation
(relationship to head of household)

HH 3 Gender

Male
Female

Has HH3 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH3 under 19 years old?

Yes
No
Don't know

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 4 of 13

HH 3 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH3 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH3 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

How does HH3 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH3 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH3 first start attending daycare or
preschool regularly?

__________________________________

HH Member 4

__________________________________
(First name only)

What is the relationship of HH4 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation

HH 4 Gender

Male
Female

Has HH4 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH4 under 19 years old?

Yes
No
Don't know

HH 4 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH4 attend preschool or daycare regularly, or
grades K-12?

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

Preschool
Daycare
Grades K-12
Does not attend any school

www.project-redcap.org

Page 5 of 13

What school does HH4 attend?

What is the name of their school?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other
__________________________________
(Only ask if "other school")

How does HH4 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH4 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH4 first start attending daycare or
preschool regularly?

__________________________________

HH Member 5

__________________________________
(First name only)

What is the relationship of HH5 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation

HH 5 Gender

Male
Female

Has HH5 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH5 under 19 years old?

Yes
No
Don't know
(estimate if needed)

HH 5 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH5 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH5 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 6 of 13

How does HH5 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH5 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH5 first start attending daycare or
preschool regularly?

__________________________________

HH Member 6

__________________________________
(First name only)

What is the relationship of HH6 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation

HH 6 Gender

Male
Female

Has HH6 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH6 under 19 years old?

Yes
No
Don't know

HH 6 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH6 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH6 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

How does HH6 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH6 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 7 of 13

At what age did HH6 first start attending daycare or
preschool regularly?

__________________________________

HH Member 7

__________________________________
(First name only)

What is the relationship of HH7 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation

HH 7 Gender

Male
Female

Has HH7 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH7 under 19 years old?

Yes
No
Don't know

HH 7 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH7 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH7 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

How does HH7 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH7 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH7 first start attending daycare or
preschool regularly?

__________________________________

HH Member 8

__________________________________
(First name only)

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 8 of 13

What is the relationship of HH8 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation

HH 8 Gender

Male
Female

Has HH8 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH8 under 19 years old?

Yes
No
Don't know

HH 8 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH8 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH8 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

How does HH8 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH8 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH8 first start attending daycare or
preschool regularly?

__________________________________

HH Member 9

__________________________________
(First name only)

What is the relationship of HH9 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation

HH 9 Gender

Male
Female

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 9 of 13

Has HH9 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH9 under 19 years old?

Yes
No
Don't know

HH 9 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

Does HH9 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH9 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

How does HH9 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH9 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH9 first start attending daycare or
preschool regularly?

__________________________________

HH Member 10

__________________________________
(First name only)

What is the relationship of HH10 to the Head of
Household?

Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Other family member
No relation

HH 10 Gender

Male
Female

Has HH10 had the flu vaccine for this season (since
August)?

Yes
No
Don't know

Is HH10 under 19 years old?

Yes
No
Don't know

HH 10 Birth month & year

__________________________________
(If unsure,give best guess for at least year)

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 10 of 13

Does HH10 attend preschool or daycare regularly, or
grades K-12?

Preschool
Daycare
Grades K-12
Does not attend any school

What school does HH10 attend?

Braddock Hills Elementary
Braddock Hills HS
Borland Manor Elementary
North Strabane Intermediate
O'Hara Elementary
Fox Chapel HS
Other

What is the name of their school?

__________________________________
(Only ask if "other school")

How does HH10 primarily spend their after school
hours? (From end of school until about 6pm)

Home alone
Home-based aftercare
Center-based aftercare
School-based aftercare/activity
Cared for by parent/family/nanny
Other

At any point before HH10 went to school, did they
attend daycare and/or preschool regularly?

Yes
No
Don't know

At what age did HH10 first start attending daycare or
preschool regularly?

__________________________________

Asthma and Smoking
Does anyone in the household have asthma?

No one has asthma
Head of household
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8
Member 9
Member 10

Does anyone in the household smoke?

No one in household smokes
Head of household
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8
Member 9
Don't know

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 11 of 13

We're interested in how flu spreads within families, particularly how it might reach older
people who are members of your family.
Are you in regular contact with the grandparents of
the children in your household?

Yes
No
Don't know
I am the only grandparent in regular contact with
them

How many grandparents of the children in your
household are you in regular contact with?

1
2
3
4
5
6

Throughout the season, we would like to ask you about
flu-like illness in these grandparents. Would you be
willing to share this information with us?

Yes
No

Grandparent 1 (GP1) Name

__________________________________

Grandparent 1 Age (if unsure, round to nearest decade)

__________________________________

In what city does Grandparent 1 normally reside?

__________________________________

In what state does GP1 normally reside?

__________________________________

Which of the following best describes how often GP1
normally sees their grandchildren that live in your
household?

Every week
At least once per month
Just at holidays (e.g. Thanksgiving or Christmas)
Less than once per year
Never

When was the last time the grandchildren in your
household saw Grandparent 1?

In the past week
In the past month
In the past 12 months
More than 12 months ago
Don't know

GP2 Name

__________________________________

GP 2 Age (if unsure, round to nearest decade)

__________________________________

In what city does GP2 normally reside?

__________________________________

In what state does GP2 normally reside?

__________________________________

Which of the following best describes how often GP2
normally sees their grandchildren that live in your
household?

Every week
At least once per month
Just at holidays (e.g. Thanksgiving or Christmas)
Less than once per year
Never

When was the last time the grandchildren in your
household saw GP 2?

In the past week
In the past month
In the past 12 months
More than 12 months ago
Don't know

GP3 Name

__________________________________

GP 3 Age (if unsure, round to nearest decade)

__________________________________

In what city does GP3 normally reside?

__________________________________

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

www.project-redcap.org

Page 12 of 13

In what state does GP3 normally reside?

__________________________________

Which of the following best describes how often GP3
normally sees their grandchildren that live in your
household?

Every week
At least once per month
Just at holidays (e.g. Thanksgiving or Christmas)
Less than once per year
Never

When was the last time the grandchildren in your
household saw GP 3?

In the past week
In the past month
In the past 12 months
More than 12 months ago
Don't know

GP4 Name

__________________________________

GP 4 Age (if unsure, round to nearest decade)

__________________________________

In what city does GP4 normally reside?

__________________________________

In what state does GP4 normally reside?

__________________________________

Which of the following best describes how often GP4
normally sees their grandchildren that live in your
household?

Every week
At least once per month
Just at holidays (e.g. Thanksgiving or Christmas)
Less than once per year
Never

When was the last time the grandchildren in your
household saw GP 4?

In the past week
In the past month
In the past 12 months
More than 12 months ago
Don't know

GP5 Name

__________________________________

GP 5 Age (if unsure, round to nearest decade)

__________________________________

In what city does GP5 normally reside?

__________________________________

In what state does GP5 normally reside?

__________________________________

Which of the following best describes how often GP5
normally sees their grandchildren that live in your
household?

Every week
At least once per month
Just at holidays (e.g. Thanksgiving or Christmas)
Less than once per year
Never

When was the last time the grandchildren in your
household saw GP 5?

In the past week
In the past month
In the past 12 months
More than 12 months ago
Don't know

GP6 Name

__________________________________

GP 6 Age (if unsure, round to nearest decade)

__________________________________

In what city does GP6 normally reside?

__________________________________

In what state does GP6 normally reside?

__________________________________

Which of the following best describes how often GP6
normally sees their grandchildren that live in your
household?

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

Every week
At least once per month
Just at holidays (e.g. Thanksgiving or Christmas)
Less than once per year
Never
www.project-redcap.org

Page 13 of 13

When was the last time the grandchildren in your
household saw GP 6?

P.I. Derek Cummings, IRB #5474, Version 11, Aug. 29, 2014

In the past week
In the past month
In the past 12 months
More than 12 months ago
Don't know

www.project-redcap.org